AVWeb discussion: the Dale Snodgrass gust-lock accident.

[Garfly]

 

 

 

[IBob]

As a relatively low hours rec pilot, I have found that I have to guard against two things:
1. An interrupted preflight, or one that deviated in some way from my normal routine, allowing missed steps loss of focus and oversights.

2. Allowing the preflight routine to become 'just' a routine, rather than actually focusing on each check: I saw this begin to creep in with my engine instrument checks, where I wasn't actually focusing on each one to verify the reading before moving on to the next: a subform of get-there-itis. I have tried to break that habit by placing my finger on each instrument as I check it, which slows me down enough to do the job properly.

 

I also notice when watching YouTube topdressing footage that the pilots 'stir the pot' with the control column prior to every single takeoff. Presumably this is due to a history of controls damage or failure in the industry, but if it's good enough for them and in view of the above, I need to make it good enough for me.......

[fallowdeer]

https://livingsafelywithhumanerror.wordpress.com/2016/05/15/usaf-c130j-accident-in-afghanistan-the-prospective-memory-failure/

[Flightrite]

Tragically it boils down to Pilot error. Being highly Experienced, at times, works against us, many hours doesn't insulate us from mistakes. 
At least for a little while this event stays in our minds and may save someone else, but it will happen again, sadly🙁

 

[RossK]

This is a perplexing one as we all think how did this guy with 1000's of hours in top level fighters, (in an environment that drills procedures into you on the basis of if you don't follow orders/procedures, someone dies) miss so much in his preflight.

It is also totally out of character by all reports.

There are numerous sources that said his preflights were typically 1hr - as you would expect of someone who has had safety procedure drilled into their brain.

Also numerous reports that he chastised people for doing intersection takeoffs and was never seen doing one himself - why leave all that runway behind you?

Yet, he missed actually phisically moving the ailerons and elevator on his walk around, missed removing the gust lock, and missed controls free and correct.

He was dead 42 minutes after his wife left the hangar and he hadn't started preflighting then.

He then did an intersection takeoff!

Something had him hurrying! What, we'll never know. Get theritis?

 

I'm sure we've all missed something on a checklist, I know I have, but not so many all at once, and all related to the controls.

And IBob is right, we can't let our checklists become routines that just prolong the time before we get airborne.

They are there for a reason - to keep us alive.

Edited July 12, 2022 by RossK

[facthunter]

I know high hours pilots who don't bother with the checklist on simple stuff.. WRONG!!. Once around the world just before opening the throttle. Knocks the other pilots legs out of the way if nothing else. Watch out when things get out of the normal for you and be more DELIBERATE than ever. on the ESSENTIAL items.  Nev

Edited July 12, 2022 by facthunter

[Garfly]

1 hour ago, fallowdeer said:

https://livingsafelywithhumanerror.wordpress.com/2016/05/15/usaf-c130j-accident-in-afghanistan-the-prospective-memory-failure/

That article on the C130 crash at Bagram has a lot of parallels with the Snodgrass one

 

Likewise this UK military Airbus incident (also with an Afghanistan connection).

 

 

 

 

 

 

[Flightrite]

The general public would be mortified if they knew what really went on in the cockpit sometimes, humans will always be humans, not machines!

[Garfly]

Yeah, I liked what the NTSB guy said in the AVweb video (OP) about attribution bias: 

 "When something bad happens to the other guy we figure it must be due to him being a dummy; when it happens to us, it must be due to a bit of bad luck."

 

 

 

 

 

Edited July 13, 2022 by Garfly

[facthunter]

IF you dig a bit deeper the Individual is afraid to acknowledge his/her inadequacies being a threat to safety so covers up the truth to themselves to maintain confidence.. Nev

[Flightrite]

That’s very true facty. Saw it so many times over many years driving heavy metal! Sim sessions were at times, a real eye opener!

[facthunter]

Yes there was a time we had to go to Toulouse for sim for each  Licence renewal and it  is done when you are very jetlagged etc and the pair of us got through the session  and the checkie said well you blokes went ok. I said how is that? Reply  MOST of the others CRASH.    Nev

[BlurE]

Sadly Humans are fallible. Even the most experienced, even with checklists. But that control lock design is truely, truely awful. Contrast that with the traditional Cessna design where the lock has a flag that blocks you from putting in the key or turning on the master. Still not perfect but so much better. I know sticks are harder than yokes but some good design could have avoided this outcome.

[facthunter]

Internal gust locks have to be complex by  their nature and if there's any chance of their failure compromising the controls forget it. Don't make the "fix" add to the risk. Just do a simple check before take off. Planes don't forgive errors or mistakes well. IF you don't GET that, don't fly. Nev

[pmccarthy]

There is a new mechanical gust lock option for Foxbat y-sticks. But I like the bungee cord version which stretches across the pilot's seat. Can’t miss it.

[facthunter]

I often used the seat belt the same way. It doesn't involve the rudder though. Nev

[Ironpot]

4 hours ago, BlurE said:

Sadly Humans are fallible. Even the most experienced, even with checklists. But that control lock design is truely, truely awful. Contrast that with the traditional Cessna design where the lock has a flag that blocks you from putting in the key or turning on the master. Still not perfect but so much better. I know sticks are harder than yokes but some good design could have avoided this outcome.

The Cessna gust lock works well and is handy when you’re at airfields with helis ground-taxying close to your aircraft. I also am a fan of the Cessna yoke but its not perfect.

 

I had a 6’6”+ passenger in the co-pilot control seat in a Cessna. I’d previously given him the preflight safety brief plus the brief for a passenger occupying a control seat about everything in front of you is live and please do not to manipulate or interfere with the controls pedals etc.

 

I’d done the preflight checklist, runups, departure brief etc then received the taxy clearance and was holding at the holding point. By coincidence, I’ve developed a habit of mentally and rapidly revisiting my checklist at the holding point: “… strobes/landing lights, code, Controls - fully free … ???“  No they xxxx weren’t - they were solidly jammed … WTF!!!

 

What had happened was sometime after completing my before takeoff and probably during the taxy,  my long legged passenger had decided to jam his knees up tight under the yoke to keep his feet away from the pedals. Made sense to him but had I just taxyed out onto the RWY and started the takeoff run, I’m not sure that I could have solved the issue. Lesson learned!

[facthunter]

That's the main purpose of the "round the world " before opening the throttles. Nev